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Malterud K. What constitutes medically professional responsibility and diligent care for children and adolescents with gender dysphoria? Tidsskr Nor Laegeforen 2023; 143:23-0181. [PMID: 37341413 DOI: 10.4045/tidsskr.23.0181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023] Open
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Slaatten H, Malterud K. Boys perpetrating sexual harassment on peer girls in secondary school: A focus group study about pupils' experiences. Scand J Public Health 2023:14034948231172250. [PMID: 37154062 DOI: 10.1177/14034948231172250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
AIMS To explore experiences of sexual harassment of adolescent girls by peer boys during school hours. METHODS Focus group study with a convenience sample of six girls and 12 boys aged 13-15 years from two different lower secondary schools in Norway. Thematic analysis with Systematic Text Condensation was used with data from three focus group discussions, supported by theory about gender performativity. RESULTS Analysis demonstrated how girls experienced specific aspects of unwanted sexual attention perpetrated by male peers. When boys trivialized sexualized behaviour perceived as intimidating by girls, the behaviour was perceived as 'normal'. Among the boys, sexual name-calling was only meant as a joke to put the girls in their place, while girls were silenced. In this way, patterns of gendered interaction contribute to performing and maintaining sexual harassment. Responses from co-pupils and teachers had strong impact on further harassment, contributing to either escalation or resistance. Signalling disapproval when being harassed was difficult when bystander behaviour was lacking or degrading. The participants wanted teachers to intervene in response to sexual harassment, emphasizing that being present or showing concern is not enough to stop the harassment. The lack of proactive responses from bystanders may also represent gender performativity, where invisibility contributes to social conventions such as normalization. CONCLUSIONS
Our analysis indicates a need for interventions targeting sexual harassment among pupils in Norwegian schools, with a special awareness of gendered performance. Both teachers and pupils would benefit from increased knowledge and skills in how to detect and stop unwanted sexual attention.
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Affiliation(s)
- Hilde Slaatten
- Regional Centre for Child and Youth Mental Health and Child Welfare, NORCE Norwegian Research Centre, Norway
| | - Kirsti Malterud
- Department of Global Public Health and Primary Care, University of Bergen, Norway
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Slagstad K, Malterud K, Brekke M, Lie AK. K. Slagstad og medarbeidere svarer. Tidsskr Nor Laegeforen 2023; 143:23-0175. [PMID: 36987897 DOI: 10.4045/tidsskr.23.0175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023] Open
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Slagstad K, Malterud K, Brekke M, Lie AK. Medisinens biopsykososiale kjønnsbegrep. Tidsskr Nor Laegeforen 2023; 143:23-0001. [PMID: 36811442 DOI: 10.4045/tidsskr.23.0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
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5
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Malterud K. 50 år siden sex mellom menn ble avkriminalisert. Tidsskriftet 2022; 142:22-0344. [DOI: 10.4045/tidsskr.22.0344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Malterud K. Developing and promoting qualitative methods in general practice research: Lessons learnt and strategies convened. Scand J Public Health 2022; 50:1024-1033. [PMID: 35603446 PMCID: PMC9578077 DOI: 10.1177/14034948221093558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Fifty years ago, qualitative research methods were unknown in medicine. Biomedicine and the positivist paradigm were universal academic standards. In the late 1980s, however, humanist perspectives emerged as substantial values in general practice. This progress fostered an effort among Nordic general practitioners to find research methods best suited to exploring clinical communication and the doctor-patient relationship. Simultaneously, qualitative methods were promoted internationally in medicine, mostly by social scientists. This article is a personal narrative of the history and impact of Nordic general practitioners customising qualitative methods for the study of clinical practice. I present lessons learnt and strategies convened in developing qualitative methods in this Nordic context. The patient-centred method paved the way for research standards consistent with our clinical ontology. We struggled to develop dialogues that promoted methodological legitimacy among medical colleagues. Methodological standards like rigour and reflexivity became important and contributed to intersubjectivity by sharing the research process. Gradually, our endeavours gained notice. In the last couple of decades, the number of published qualitative studies has increased, though perhaps at the cost of methodological quality. Indeed, there are also indications of a methodological backlash among influential journal editors. Nordic general practitioners have been prominent in developing qualitative methods suitable for cultivation of medical knowledge. Our position of knowing, close to the experiences of the individual patient and the everyday context, is different from that of a social scientist. It offers a unique point of departure for knowledge development that can make an important difference for both patients and doctors.
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Affiliation(s)
- Kirsti Malterud
- Department of Global Public Health and Primary Care, University of Bergen, Norway
- Department of Public Health, University of Copenhagen, Denmark
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7
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Abstract
General practitioners (GPs) often find that linear, deductive knowledge does not provide a sufficient map for clinical management. But experience, accompanied by enduring familiarity with individual patients, may offer unique complementary skills to interpret a patient's symptoms and navigate skilfully through diagnosis, treatment, follow-up and prevention.In this article, we draw attention to the nature of this tacit knowing that is executed by many GPs every day. We argue that the nonlinear, unpredictable complexity of this domain nurtures a particular logic of clinical knowing. This kind of knowledge is not intuition and can to some extent be intersubjectively accessible. We substantiate and discuss how and why general practice research can contribute to knowledge development by transforming reflection-in-action to reflection-on-action.We briefly present some concepts for reflection-on-action of clinical knowing in general practice. The VUCA model (volatility, uncertainty, complexity, ambiguity) embraces dynamic and confusing situations in which agile work (adaptive, flexible and responsive behaviour and cognitive creativity) is assumed to be an appropriate response. Using such perspectives, we may sharpen our gaze and apply reflexivity and analytic elaboration to interpret unique incidents and experiences and appreciate the complexity of general practice. In this way, exploratory research can fertilize general practice and offer innovation to the entire domain of clinical knowledge.
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Affiliation(s)
- Kirsti Malterud
- Research Unit for General Practice, NORCE Norwegian Research Centre, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- The Research Unit and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- CONTACT Kirsti Malterud Research Unit for General Practice, NORCE Norwegian Research Centre, Årstadveien 17, N-5009, Norway
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Guassora AD, Johansen ML, Malterud K. Agenda navigation in consultations covering multiple topics. A qualitative case study from general practice. Scand J Prim Health Care 2021; 39:339-347. [PMID: 34435549 PMCID: PMC8475129 DOI: 10.1080/02813432.2021.1958472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To explore how agenda navigation may be accomplished underway in consultations covering multiple topics, we identified and analyzed one GP's communicative strategies. DESIGN, SETTING, AND SUBJECTS A qualitative observational case study with linguistic microanalysis of an exemplary consultation between a female patient with diabetes and her male GP. We used speech act theory to identify communicative actions that indicated agenda navigation by the GP in transitions between episodes concerning ten topics. RESULTS Microanalysis revealed different aspects of agenda navigation by the GP using speech acts, especially ways of opening or closing an episode. The opening of episodes was characterized by speech acts accepting the patient's request to discuss a topic, mostly at the beginning of the consultation. Speech acts to inform or to request information from the patient dominated later in the consultation. The GP closed all episodes using speech acts to instruct or appraise the patient, or to make agreements and plans. CONCLUSION AND PRACTICE IMPLICATIONS Skilful agenda navigation is an important tool for consultations covering multiple issues and could be further developed for medical education. The opening and closing of episodes were vital communicative strategies supporting patient-centered communication in a complex consultation while maintaining the focus of the consultation agenda.KEY POINTSWhile traditional consultation models cover one health problem, GP consultations often include many patient issues in each session.Linguistic microanalysis of speech acts helped to identify communication strategies in a GP consultation with multiple topics.The GP conducted agenda navigation by distinctly opening and closing episodes concerning specific topics.Episodes were opened by accepting, informing, and requesting and closed by instruction, appraisal, making agreements, or plans.
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Affiliation(s)
- Ann Dorrit Guassora
- The Research Unit and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- CONTACT Ann Dorrit Guassora The Research Unit and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - May-Lill Johansen
- The Research Unit for General Practice, Department of Community Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Kirsti Malterud
- The Research Unit and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Research Unit for General Practice, NORCE Norwegian Research Centre, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Norway
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Abstract
Objective: To explore experiences motivating doctors to become and remain GPs.Design and contributors: Qualitative analysis of written responses from an open-ended question about motivational experiences posted on an internet discussion list for GPs in Norway. Texts from 25 contributors were analysed with Systematic Text Condensation, supported by theories about calling as motivation.Results: Analysis revealed numerous aspects of motivation to become and remain a general practitioner. Inspirations from early experiences and skilled role models had conveyed values and offered insight into a fascinating world of care, gratitude and respect. Close and continuous relationships with patients provided GPs with humbling experiences and learning moments. Contributors described how these encounters became rewarding sources of insight and mutual trust, improving interpersonal skills. Also, the extensive variety of tasks during the workday and the space for autonomy and independence was emphasised.Implications: Understanding motivational experiences influencing GPs' choice of medical career is necessary to develop strategies for recruitment and stability and contribute to prevention of burn-out and improper work-life balance. GPs' professional identities and commitments should be recognized and developed in dialogues between authorities and GPs to enhance communication, improve the structural frames of work environment and thereby sustainable recruitment.Key pointsGPs regard their choice of medical career as strongly influenced by motivational experiences in childhood, adolescence and as medical studentsRole models, diversity of work, feelings of being able to contribute and rewarding and continuous relationships with patients were mentioned to activate and maintain general practice commitmentKnowledge about motivational influences, professional identities and commitment for GPs is crucial for medical education and dialogue to promote general practice as a career choice and prevent dangers of work overload and burnout.
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Affiliation(s)
- Inga Marthe Gronseth
- Research Unit for General Practice, NORCE Norwegian Research Centre, Bergen, Norway;
- CONTACT Inga Marthe Gronseth Research Unit for General Practice, NORCE Norwegian Research Centre, Bergen, Norway
| | - Kirsti Malterud
- Research Unit for General Practice, NORCE Norwegian Research Centre, Bergen, Norway;
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway;
- The Research Unit and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Stein Nilsen
- Research Unit for General Practice, NORCE Norwegian Research Centre, Bergen, Norway;
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Abstract
Objective: To describe experiences among general practitioners (GPs) in Norway regarding horizontal task shifting experiences associated with adverse events that potentially put patient safety at risk.Design and contributors: We conducted a qualitative study with data from a retrospective convenience sample of consecutive, already posted comments in a restricted Facebook group for GPs in Norway. The sample consisted of 43 unique posts from 38 contributors (23 women and 15 men), presenting thick and specific accounts of potentially adverse events in the context of horizontal task shifting. Analysis was conducted with systematic text condensation, a method for thematic cross-case analysis.Results: Contributing GPs reported several types of adverse events associated with horizontal task shifting that could put patient safety at risk. They described how spill-over work dispatched to GPs may generate administrative hassle and hazardous delay of necessary examinations. Overdiagnosis, reduced access and endangered accountability occur when time-consuming procedures and pre-investigation before referral are pushed upon GPs. Resource-draining chores beyond GPs' proficiency is also dispatched without appropriate instruction or equipment. Furthermore, potential malpractice is imposed by hospital colleagues who overrule the GPs' medical judgement.Implications: Patient safety is endangered when horizontal task shifting is initiated and performed without a systematic process involving all stakeholders that considers available resources. A risk and vulnerability analysis, securing competent staff, resources, time and equipment before launching such reforms is necessary to protect patient safety. Infrastructure comprised of local coordination groups may facilitate dialogue between health care service levels and negotiate responsibilities and workload.Key pointsTask shifting between different levels of health care is a relevant and legitimate strategy for planning and policy.GPs in Norway report adverse events related to task shifting from specialist colleagues without proper resource allocation.Patient safety may be put at risk by hazardous delay, overdiagnosis, endangered accountability and potential malpractice.Planning and implementation of task shifting must involve all system levels and relevant stakeholders to ensure patient safety.
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Affiliation(s)
- Kirsti Malterud
- Research Unit for General Practice, NORCE Norwegian Research Centre, Bergen, Norway;
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway;
- The Research Unit and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark;
- CONTACT Kirsti Malterud Research Unit for General Practice, Kalfarveien 31, N-5032 Bergen, Norway
| | - Aase Aamland
- Research Unit for General Practice, NORCE Norwegian Research Centre, Bergen, Norway;
- Health, Care and Social Services, County Governor of Agder, Arendal, Norway;
| | - Anette Fosse
- Research Unit for General Practice, NORCE Norwegian Research Centre, Bergen, Norway;
- National Centre of Rural Medicine, Department of Community Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
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11
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Anderssen N, Sivertsen B, Lønning KJ, Malterud K. Life satisfaction and mental health among transgender students in Norway. BMC Public Health 2020; 20:138. [PMID: 32000747 PMCID: PMC6993484 DOI: 10.1186/s12889-020-8228-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 01/16/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Social attitudes to transgender persons and other gender minorities vary around the world, and in many cultures, prejudices and social stigma are common. Consequently, transgender persons face challenges related to discrimination and negative attitudes among the public. The purpose of this study was to compare life satisfaction, loneliness, mental health, and suicidal behavior among transgender students with cisgender students' experiences in a nationwide sample of Norwegian students pursuing higher education. METHODS In total,50,054 full-time Norwegian students completed an online questionnaire (response rate 30.8%), of whom 15,399 were cisgender males, 34,437 cisgender females, 28 individuals who reported being binary transgender (12 transwomen and 16 transmen), and 69 individuals non-binary transgender persons. The measures included questions concerning gender identity, life satisfaction (Satisfaction With Life Scale), loneliness (The Three-Item Loneliness Scale), mental health problems (Hopkins Symptoms Check List), mental disorders, and suicidal ideation, suicidal behavior, and self-harm. Chi-square tests, Independent-Samples Kruskal-Wallis tests, and logistic regression analyses were used to examine differences between gender identities. RESULTS Transgender students reported significantly more psychosocial burdens on all measures. There were no significant differences in any of the measures between the binary and non-binary transgender students. CONCLUSION The findings call for increased awareness about welfare and health for transgender students in Norway. Higher education institutions need to consider measures at various levels to establish a learning environment that is more inclusive for gender minorities.
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Affiliation(s)
- Norman Anderssen
- Department of Psychosocial Science, Faculty of Psychology, University of Bergen, Bergen, Norway. .,Research Unit for General Practice, NORCE Norwegian Research Centre, Bergen, Norway.
| | - Børge Sivertsen
- Department of Health Promotion, Norwegian Institute of Public Health, Bergen, Norway.,Department of Research & Innovation, Helse Fonna HF, Haugesund, Norway.,Department of Mental Health, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kari Jussie Lønning
- The Norwegian Medical Association, Oslo, Norway.,The Student Welfare Organization of Oslo and Akershus (SiO), Oslo, Norway
| | - Kirsti Malterud
- Research Unit for General Practice, NORCE Norwegian Research Centre, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,The Research Unit and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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12
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Abstract
Background: Getting the right diagnosis is supposed to provide an explanation of a patient's health problem and inform health care decisions. As a core element of clinical reasoning, diagnosis deserves systematic and transparent analysis. Conceptual tools can make doctors become aware of and explore diagnostic knowing.Methods: We demonstrate diagnostic knowing analysed as interpretative and contextualised activity. Our analysis is based on Lonergan's theory of knowing, constituting the cognitive structures as experiencing, understanding, and judging, in a general practice case.Findings: Analysis makes the complexity of diagnostic knowing in this context more transparent, in this case concluding with four diagnostic labels: a corn, constipation, headache and atrial fibrillation. We demonstrate how a medically significant diagnosis does not necessarily evolve deductively from complaints. The opening lines from the patient give ideas of where to look for possible explanations - questions for understanding - rather than diagnostic hypotheses. Such questions emerge from the GP's experiences from meeting the patient, including imaginations and interpretations. When ideas and questions regarding diagnoses have been developed, they may be judged and subjected to reflection. Questioning may also emerge as transitory concerns, not extensively ruled out. Lonergan's theory demonstrated a strong fit with these aspects of diagnostic knowing in general practice.Implications: Analysis demonstrated systematic, transparent approaches to diagnostic knowing, relevant for clinical teaching. We argue that an interpretative understanding of diagnosis can change clinical practice, complementing hypothetico-deductive strategies by recognising additional substantial diagnostic modes and giving access to scholarly reflection.Key PointsDiagnosis is a core element of clinical reasoning, deserving systematic and transparent analysis beyond hypothetico-deductive reasoning or pattern recognitionDiagnostic knowing in general practice is a special instance of all human knowing with subjectivity, interpretation and reflexivity as essential elementsLonergan's theory for knowing based on experiencing, understanding, and judging allowed us to map, decode and recognise advanced acts of clinical reasoning We share our experiences of how these concepts gave us a tool for systematic analysis of the complexities taking place in the GP's office on an ordinary day.
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Affiliation(s)
- Kirsti Malterud
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark;
- Research Unit for General Practice, NORCE Norwegian Research Centre, Bergen, Norway;
- Department of Global Public Health and Primary Care, University of Bergen, Norway
- CONTACT Kirsti Malterud Research Unit for General Practice, Kalfarveien 31, N-5018 Bergen, Norway
| | - Susanne Reventlow
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark;
| | - Ann Dorrit Guassora
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark;
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Hafting M, Gullbrå F, Anderssen N, Rørtveit G, Smith-Sivertsen T, Malterud K. Burdened parents sharing their concerns for their children with the doctor. The impact of trust in general practice: a qualitative study. Scand J Prim Health Care 2019; 37:327-334. [PMID: 31309855 PMCID: PMC6713169 DOI: 10.1080/02813432.2019.1639907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Objective: The aim of this study was to recognise the preconditions experienced by general practitioners (GPs) in addressing the children's needs when ill and substance abusing parents consult for their own health problems. Design: Qualitative analysis of 38 case stories told by GPs in focus group interviews. Setting: Focus group interviews of four continuing medical education groups for GPs in western Norway. Subjects: 27 GPs (nine females) with at least 5 years' experiences in general practice. Results: Different aspects of the GPs' perceived mandate of trust from the parents was a precondition for the children's situation to be addressed. In some case stories the participants took an open mandate from the parent for granted, while in others they assumed that the parent did not want to discuss their family situation. Sometimes the participants had faith that by continuing with their ordinary GP tasks, they might obtain a more open mandate of trust. Their evaluation of the mandate of trust seemed to impact on how the GP could adopt a mediating role between the parents and various support agencies, thus supporting children who were at risk. Discussion/conclusion: The children most at risk may remain invisible in GPs' encounters with their parents, possibly because their parent's health problems and overall situation overshadow the children's situation. The mandate of trust from burdened parents to GPs can be a fruitful concept in understanding the interaction regarding the welfare of the parent's children. Negotiating the mandate of trust with parents by explicitly addressing trust and having an ongoing discussion about the mandate and its limits might be an option to secure the children support if necessary. KEY POINTS Offering children of burdened parents information and support can be crucial for health promotion and illness prevention. A general practitioner's (GP's) evaluation of the trust parents have in them can determine the extent of support children receive. Depending on the parents' level of trust, GPs may take a mediating role between support services and parents for the benefit of the children. A negotiation concerning the trust parents have in the GP may open up possibilities for GPs to offer children necessary support.
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Affiliation(s)
- Marit Hafting
- Regional Centre for Child and Youth Mental Health and Child Welfare, NORCE Norwegian Research Center, Bergen, Norway;
- CONTACT Marit Hafting Regional Centre for Child and Youth Mental Health and Child Welfare, NORCE Norwegian Research Center, Bergen, Norway
| | - Frøydis Gullbrå
- Research Unit for General Practice, NORCE Norwegian Research Center, Bergen, Norway;
| | - Norman Anderssen
- Research Unit for General Practice, NORCE Norwegian Research Center, Bergen, Norway;
- Department of Psychosocial Science, University of Bergen, Bergen, Norway;
| | - Guri Rørtveit
- Research Unit for General Practice, NORCE Norwegian Research Center, Bergen, Norway;
- Research Group for General Practice, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway;
| | - Tone Smith-Sivertsen
- Research Unit for General Practice, NORCE Norwegian Research Center, Bergen, Norway;
| | - Kirsti Malterud
- Research Unit for General Practice, NORCE Norwegian Research Center, Bergen, Norway;
- Research Group for General Practice, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway;
- Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Malterud K, Elvbakken KT. Patients participating as co-researchers in health research: A systematic review of outcomes and experiences. Scand J Public Health 2019; 48:617-628. [PMID: 31319762 DOI: 10.1177/1403494819863514] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Aims: We aimed to map out the scope and type of health research studies with patients involved as co-researchers throughout the research process and to explore the outcomes and experiences of such research. Methods: We conducted a narrative review by systematically searching selected databases. A total of 1451 hits were identified and screened, and 17 studies were included and categorised by type of health problem, design, publication sources and modes of presentation. We conducted an inductive, iterative analysis of outcomes and experiences of patient involvement. Results: We identified two types of impact from studies with patients participating as co-researchers: (a) patient involvement as primary focus, where seven articles largely reported and reflected upon the shared experiences, and (b) patient involvement as strategy, where 10 articles presented results from empirical studies of specific health problems, with patient involvement used as a strategy to expand understanding. The first group of studies reported collaborative processes and resource investments, while the second group addressed specific health problems from a distinctive perspective due to patient involvement. Several studies in both groups repeated or confirmed positive values of user involvement rather than providing original findings. In both groups, methodological standards were often downgraded to provide access for the co-researchers. Conclusions: These articles, where the co-researcher model represents the contemporary superior level of patient involvement, may indicate that mere collaboration efforts are prioritised at the expense of knowledge outcomes and scientific quality. Collaboration formats other than participation as co-researchers may be necessary for patient involvement in medical research to add to the existing knowledge.
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Affiliation(s)
- Kirsti Malterud
- Research Unit for General Practice, NORCE Norwegian Research Centre, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Norway.,Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Denmark
| | - Kari Tove Elvbakken
- Department of Administration and Organization Theory, University of Bergen, Norway
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Abstract
Qualitative metasynthesis, developed as an interpretative and inductive methodology, is increasingly influenced by standards from evidence-based medicine, established as a strategy to support policy decisions and guidelines. Currently, principles and procedures from the format developed for systematic reviews are often applied for review and synthesis of all kinds of evidence, including results from qualitative studies. In this article, I substantiate these claims, discussing benefits to be harvested and warnings to be given when qualitative metasynthesis approaches the evidence-based medicine methodology. Situating my exploration in the context of clinical practice, I contrast missions and values of these methodologies regarding review and synthesis of research literature, highlighting potential mismatches between ontology and epistemology, emphasizing challenges regarding sample, analysis, and transferability. Approving systematic and transparent strategies as generic for such purposes, I warn against the idea that methodology developed for evidence-based medicine is a universal gold standard for synthesis of research evidence.
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Affiliation(s)
- Kirsti Malterud
- 1 Uni Research Health, Bergen, Norway
- 2 University of Bergen, Norway
- 3 University of Copenhagen, Denmark
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16
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Malterud K, Bjelland AK, Elvbakken KT. Systematic reviews for policy-making - critical reflections are needed. Health Res Policy Syst 2018; 16:112. [PMID: 30458786 PMCID: PMC6245825 DOI: 10.1186/s12961-018-0387-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 10/24/2018] [Indexed: 11/10/2022] Open
Affiliation(s)
- Kirsti Malterud
- Research Unit for General Practice, NORCE Norwegian Research Centre, Bergen, Norway.
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
| | | | - Kari Tove Elvbakken
- Department of Administration and Organization Theory, University of Bergen, Bergen, Norway
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Ree E, Johnsen TL, Harris A, Malterud K. Workplace inclusion of employees with back pain and mental health problems: A focus group study about employees' experiences. Scand J Public Health 2018; 47:326-333. [PMID: 30301425 PMCID: PMC6492234 DOI: 10.1177/1403494818799611] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aim: To explore how employees experience workplace inclusion of
their colleagues or themselves when having back pain or mental health problems.
Methods: Three focus group interviews with a sample of 16
kindergarten employees were conducted. Systematic Text Condensation was used for
analysis. Results: The participants emphasized that it was
easier to include colleagues whose health problems were specific, especially
when they were open about having problems and expressed their needs for
accommodation clearly. Discussions revealed difficulties of acceptance and
accommodating colleagues with longstanding health problems, when the burden on
the other staff members was heavy, and if it had negative consequences for the
kindergarten children. Some of the participants had experienced health problems
themselves, which was also described as challenging. Having health problems at
work often induced feelings of guilt, being a burden to their colleagues, and
experiencing a disparity between the ideals and the realities of inclusion
practices. Conclusions: Workplace inclusion of employees
is difficult when their health problems are unspecific, longstanding, and
lead to negative consequences for children or colleagues. System level
efforts are necessary to reduce negative stereotypes about employees with
health problems and facilitate inclusion practices.
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Affiliation(s)
- Eline Ree
- 1 Division of Physical Medicine and Rehabilitation, Vestfold Hospital Trust, Stavern, Norway.,2 Faculty of Health Sciences, Centre for Resilience in Healthcare (SHARE), University of Stavanger, Stavanger, Norway
| | - Tone Langjordet Johnsen
- 1 Division of Physical Medicine and Rehabilitation, Vestfold Hospital Trust, Stavern, Norway
| | - Anette Harris
- 3 Department of Psychosocial Science, University of Bergen, Bergen, Norway
| | - Kirsti Malterud
- 4 Research Unit for General Practice, NORCE Norwegian Research Centre, Bergen, Norway.,5 Department of Global Public Health and Primary Care, University of Bergen, Norway.,6 The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Willadsen TG, Siersma V, Nielsen ABS, Køster-Rasmussen R, Guassora AD, Jarbøl DE, Eusebi P, Malterud K, Reventlow S, de Fine Olivarius N. The effect of structured personal care on diabetes symptoms and self-rated health over 14 years after diabetes diagnosis. Prim Care Diabetes 2018; 12:354-363. [PMID: 29705674 DOI: 10.1016/j.pcd.2018.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/23/2018] [Accepted: 03/29/2018] [Indexed: 10/17/2022]
Abstract
AIMS To explore the effect of structured personal care on diabetes symptoms and self-rated health over 14 years after diabetes diagnosis while patients are gradually diagnosed with other chronic conditions (multimorbidity). METHODS Post hoc analysis of the Danish randomized controlled trial Diabetes Care in General Practice including 1381 patients newly diagnosed with type 2 diabetes. The effect of structured personal care compared with routine care on diabetes symptoms and self-rated health was analysed 6 and 14 years after diagnosis with a generalized multilevel Rasch model. RESULTS Structured personal care reduced the overall likelihood of reporting diabetes symptoms at the end of the intervention (OR 0.79; 95% CI: 0.64-0.97), but this effect was not explained by glycaemic control or multimorbidity. There was no effect of the intervention on diabetes symptoms after 14 years or on self-rated health after 6 years or 14 years. CONCLUSIONS Structured personal care had a beneficial effect on diabetes symptoms 6 years after diagnosis, but not on self-rated health at either follow up point. To optimally manage patients over time it is important to supplement clinical information by information provided by the patients.
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Affiliation(s)
- Tora Grauers Willadsen
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
| | - Volkert Siersma
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Anni Brit Sternhagen Nielsen
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Rasmus Køster-Rasmussen
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Ann Dorrit Guassora
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Dorte Ejg Jarbøl
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Paolo Eusebi
- Section of Neurology, Department of Medicine, University of Perugia, Perugia, Italy; Health Planning Service, Department of Epidemiology, Regional Health Authority of Umbria, Perugia, Italy
| | - Kirsti Malterud
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark; Research Unit for General Practice, Uni Research Health, Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, Norway
| | - Susanne Reventlow
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Niels de Fine Olivarius
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Affiliation(s)
- Trisha Greenhalgh
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sally Thorne
- School of Nursing, University of British Colombia, Vancouver, BC, Canada
| | - Kirsti Malterud
- Research Unit for General Practice, Uni Research Health, Bergen, Norway
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Malterud K, Aamland A, Iden KR. Small-scale implementation with pragmatic process evaluation: a model developed in primary health care. BMC Fam Pract 2018; 19:93. [PMID: 29929482 PMCID: PMC6014026 DOI: 10.1186/s12875-018-0778-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 05/25/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Research often fails to impose substantial shifts in clinical practice. Evidence-based health care requires implementation of documented interventions, with implementation research as a science-informed strategy to identify core experiences from the process and share preconditions for achievement. Evidence developed in hospital contexts is often neither relevant nor feasible for primary care. Different evidence types may constitute a point of departure, stretching and testing the transferability of the intervention by piloting it in primary care. Comprehensive descriptions of aims, context and procedures can be a more useful outcome than traditional effect studies. MAIN TEXT We present a model for small-scale implementation of relevant research evidence, monitored by pragmatic evaluation. The model, which is applicable in primary care, is supported by Weiner's theory about organizational readiness for change and consists of four steps: 1) recognize the problem - identify a workable intervention, 2) assess the context - prepare for inception, 3) pilot the intervention on site, and 4) upscale and accomplish the intervention. The process is evaluated by exploring selected relevant aspects of experiences and outcomes from the first to the last step. Process evaluation is a logical precondition for outcome evaluation - attempting to assess either the efficacy or the effectiveness of a "black box" intervention makes no sense. We argue why evidence beyond effect studies and evaluation beyond randomized controlled trials may be adequate for science-informed evaluation of a small-scale implementation project such as is often conducted by primary health care practitioners. The model is illustrated by an ongoing project, in which a strategy for upgrading the management of depression in nursing homes in Norway is currently being implemented. CONCLUSIONS A flexible and manageable approach is suggested, in which the inevitable unpredictability of clinical practice is incorporated. Finding the appropriate middle ground between rigour and flexibility, some compromises must be made. Our model recognizes the skills of practical knowing as something other than traditional medical research, while maintaining academic values such as systematic and transparent reflection, using adequate tools. Considering the purpose and context of our model, we argue that these priorities, emphasizing relevance and feasibility, are strengths, not limitations.
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Affiliation(s)
- Kirsti Malterud
- Research Unit for General Practice, Uni Research Health, Uni Research, Kalfarveien 31, N-5018 Bergen, Norway
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Aase Aamland
- Research Unit for General Practice, Uni Research Health, Uni Research, Kalfarveien 31, N-5018 Bergen, Norway
| | - Kristina Riis Iden
- Research Unit for General Practice, Uni Research Health, Uni Research, Kalfarveien 31, N-5018 Bergen, Norway
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Greenhalgh T, Thorne S, Malterud K. Time to challenge the spurious hierarchy of systematic over narrative reviews? Eur J Clin Invest 2018; 48:e12931. [PMID: 29578574 PMCID: PMC6001568 DOI: 10.1111/eci.12931] [Citation(s) in RCA: 270] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 03/20/2018] [Indexed: 12/12/2022]
Affiliation(s)
- Trisha Greenhalgh
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sally Thorne
- School of Nursing, University of British Colombia, Vancouver, Canada
| | - Kirsti Malterud
- Research Unit for General Practice, Uni Research Health, Bergen, Norway
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Abstract
AIMS This study aims to explore how minority stress related to sexual orientation is reflected in narratives from lesbian, gay and bisexual (LGB) individuals in Norway, with an impact for national public health policy. METHODS Arthur Frank's dialogical narrative analysis was applied to personal stories from 65 persons self-referring to different categories of queer identities, submitted online anonymously to a Norwegian national archive for queer history. A purposive sample of three different stories were selected due to their capacity to illuminate how various aspects of minority stress are narrated in diverse interplays between individual voices and resources, and cultural scripts and societal influences. RESULTS Our analysis highlighted how stories may offer significant glimpses into the dynamic and complex fashioning of sexual identities, giving precious clues to the vulnerabilities and strengths of the narrator. Contemporary queer narratives from Norway reflect meaning-making related to sexual orientation that are influenced by, and expand upon, the classical scripts dominated by tragedy and tristesse, personal progress or simply no particular tension. LGB individuals of different ages and backgrounds had experienced aspects of minority stress related to their sexual orientation, with a substantial impact on identity, even when significant others were encouraging. CONCLUSIONS The stories indicate that positive proximal processes, such as personal resilience and sympathetic environments, can support mental health and counteract negative effects of distal processes contributing to minority stress, such as heteronormativity and subtle microaggression. Public health strategies addressing attitudes to sexual orientation among the general population may contribute to diverse affirmative cultural scripts about queer lives, thereby enhancing queer mental health.
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Affiliation(s)
- Oddgeir Synnes
- 1 Centre of Diaconia and Professional Practice, VID Specialized University, Oslo, Norway
| | - Kirsti Malterud
- 2 Research Unit for General Practice, Uni Research Health, Bergen, Norway.,3 Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,4 The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Affiliation(s)
- Trisha Greenhalgh
- Trisha Greenhalgh is with the Department of Primary Care Health Sciences, University of Oxford, Oxford, UK. Kirsti Malterud is with the Research Unit for General Practice, Uni Research Health, Uni Research, Bergen, Norway
| | - Kirsti Malterud
- Trisha Greenhalgh is with the Department of Primary Care Health Sciences, University of Oxford, Oxford, UK. Kirsti Malterud is with the Research Unit for General Practice, Uni Research Health, Uni Research, Bergen, Norway
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Malterud K. Metodebok for ikke-forskere? Tidsskriftet 2018. [DOI: 10.4045/tidsskr.18.0280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Malterud K. Kvinnehelse, kjønn og trange livsrom. Tidsskriftet 2018; 138:18-0715. [DOI: 10.4045/tidsskr.18.0715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Abstract
Qualitative methodology is gaining increasing attention and esteem in medical research, with general practice research taking a lead. With these methods, human and social interaction and meaning can be explored and shared by systematic interpretation of text from talk, observation or video. Qualitative studies are often included in Ph.D. theses from general practice in Scandinavia. Still, the Ph.D. programs across nations and institutions offer only limited training in qualitative methods. In this opinion article, we draw upon our observations and experiences, unpacking and reflecting upon values and challenges at stake when qualitative studies are included in Ph.D. theses. Hypotheses to explain these observations are presented, followed by suggestions for standards of evaluation and improvement of Ph.D. programs. The authors conclude that multimethod Ph.D. theses should be encouraged in general practice research, in order to offer future researchers an appropriate toolbox.
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Affiliation(s)
- Kirsti Malterud
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Research Unit for General Practice, Uni Research Health, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- CONTACT Kirsti Malterud Research Unit for General Practice, Kalfarveien 31, N-5018 Bergen, Norway
| | - Katarina Hamberg
- Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden
| | - Susanne Reventlow
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Anderssen N, Malterud K. Oversampling as a methodological strategy for the study of self-reported health among lesbian, gay and bisexual populations. Scand J Public Health 2017; 45:637-646. [PMID: 28675963 DOI: 10.1177/1403494817717407] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIMS Epidemiological research on lesbian, gay and bisexual populations raises concerns regarding self-selection and group sizes. The aim of this research was to present strategies used to overcome these challenges in a national population-based web survey of self-reported sexual orientation and living conditions-exemplified with a case of daily tobacco smoking. METHODS The sample was extracted from pre-established national web panels. Utilizing an oversampling strategy, we established a sample including 315 gay men, 217 bisexual men, 789 heterosexual men, 197 lesbian women, 405 bisexual women and 979 heterosexual women. We compared daily smoking, representing three levels of differentiation of sexual orientation for each gender. RESULTS The aggregation of all non-heterosexuals into one group yielded a higher odds ratio (OR) for non-heterosexuals being a daily smoker. The aggregation of lesbian and bisexual women indicated higher OR between this group and heterosexual women. The full differentiation yielded no differences between groups except for bisexual compared with heterosexual women. CONCLUSIONS The analyses demonstrated the advantage of differentiation of sexual orientation and gender, in this case bisexual women were the main source of group differences. We recommend an oversampling procedure, making it possible to avoid self-recruitment and to increase the transferability of findings.
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Affiliation(s)
- Norman Anderssen
- 1 Research Unit for General Practice, Uni Health Research, Bergen, Norway.,2 Department of Psychosocial Science, University of Bergen, Norway
| | - Kirsti Malterud
- 1 Research Unit for General Practice, Uni Health Research, Bergen, Norway.,3 Department of Global Public Health and Primary Care, University of Bergen, Norway.,4 The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Denmark
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Abstract
OBJECTIVE To explore general practitioners (GPs') experiences from consultations when a patient's request is denied, and outcomes of such incidents. DESIGN AND PARTICIPANTS We conducted a qualitative study with semi-structured individual interviews with six GPs in Norway. We asked them to tell about experiences from specific encounters where they had refused a patient's request. The texts were analysed with Systematic Text Condensation, a method for thematic cross-case analysis. MAIN OUTCOME MEASURES Accounts of experiences from consultations when GPs refused their patients' requests. RESULTS Subjects of dispute included clinical topics like investigation and treatment, certification regarding welfare benefits and medico-legal issues, and administrative matters. The arguments took different paths, sometimes settled by reaching common ground but more often as unresolved disagreement with anger or irritation from the patient, sometimes with open hostility and violence. The aftermath and outcomes of these disputes lead to strong emotional impact where the doctors reflected upon the incidents and sometimes regretted their handling of the consultation. Some long-standing and close patient-doctor relationships were injured or came to an end. CONCLUSIONS The price for denying a patient's request may be high, and GPs find themselves uncomfortable in such encounters. Skills pertaining to this particular challenge could be improved though education and training, drawing attention to negotiation of potential conflicts. Also, the notion that doctors have a professional commitment to his or her own autonomy and to society should be restored, through increased emphasis on core professional ethics in medical education at all levels.
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Affiliation(s)
- Stein Nilsen
- Research Unit for General Practice, Uni Research Health, Bergen, Norway
- CONTACT Stein Nilsen Research Unit for General Practice, Uni Research Health, Kalfarveien 31, N-5018 Bergen, Norway
| | - Kirsti Malterud
- Research Unit for General Practice, Uni Research Health, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Fosse A, Zuidema S, Boersma F, Malterud K, Schaufel MA, Ruths S. Nursing Home Physicians' Assessments of Barriers and Strategies for End-of-Life Care in Norway and The Netherlands. J Am Med Dir Assoc 2017; 18:713-718. [PMID: 28465128 DOI: 10.1016/j.jamda.2017.03.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 03/11/2017] [Accepted: 03/13/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Working conditions in nursing homes (NHs) may hamper teamwork in providing quality end-of-life (EOL) care, especially the participation of NH physicians. Dutch NH physicians are specialists or trainees in elderly care medicine with NHs as the main workplace, whereas in Norway, family physicians usually work part time in NHs. Thus, we aimed at assessing and comparing NH physicians' perspectives on barriers and strategies for providing EOL care in NHs in Norway and in The Netherlands. DESIGN A cross-sectional study using an electronic questionnaire was conducted in 2015. SETTING AND PARTICIPANTS All NH physicians in Norway (approximately 1200-1300) were invited to participate; 435 participated (response rate approximately 35%). Of the total 1664 members of the Dutch association of elderly care physicians approached, 244 participated (response rate 15%). MEASUREMENTS We explored NH physicians' perceptions of organizational, educational, financial, legal, and personal prerequisites for quality EOL care. Differences between the countries were compared using χ2 test and t-test. RESULTS Most respondents in both countries reported inadequate staffing, lack of skills among nursing personnel, and heavy time commitment for physicians as important barriers; this was more pronounced among Dutch respondents. Approximately 30% of the respondents in both countries reported their own lack of interest in EOL care as an important barrier. Suggested improvement strategies were routines for involvement of patients' family, pain- and symptom assessment protocols, EOL care guidelines, routines for advance care planning, and education in EOL care for physicians and nursing staff. CONCLUSIONS Inadequate staffing levels, as well as lack of competence, time, and interest emerge as important barriers to quality EOL care according to Dutch and Norwegian NH physicians. Their perspectives were mostly similar, despite large educational and organizational differences. Key strategies for improving EOL care in their facilities comprise education and incorporating available palliative care tools and systems.
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Affiliation(s)
- Anette Fosse
- Research Unit for General Practice, Uni Research Health, Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.
| | - Sytse Zuidema
- Department of General Practice and Elderly Care Medicine, University of Groningen, Groningen, The Netherlands
| | - Froukje Boersma
- Department of General Practice and Elderly Care Medicine, University of Groningen, Groningen, The Netherlands
| | - Kirsti Malterud
- Research Unit for General Practice, Uni Research Health, Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Margrethe Aase Schaufel
- Research Unit for General Practice, Uni Research Health, Bergen, Norway; Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway
| | - Sabine Ruths
- Research Unit for General Practice, Uni Research Health, Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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Werner A, Malterud K. How can professionals carry out recognition towards children of parents with alcohol problems? A qualitative interview study. Scand J Public Health 2017; 45:42-49. [PMID: 27903795 DOI: 10.1177/1403494816680802] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIM The aim of this study was to explore informal adult support experienced by children with parental alcohol problems to understand how professionals can show recognition in a similar way. METHODS We conducted a qualitative interview study with retrospective accounts from nine adults growing up with problem-drinking parents. Data were analysed with systematic text condensation. Goffman's concept "frame" offered a lens to study how supportive situations were defined and to understand opportunities and limitations for translation of recognition acts and attitudes to professional contexts. RESULTS Analysis demonstrated frames of commonplace interaction where children experienced that adults recognised and responded to their needs. However, the silent support from an adult who recognised the problems without responding was an ambiguous frame. The child sometimes felt betrayed. Concentrating on frames of recognition which could be passed over to professional interactions, we noticed that participants called for a safe harbour, providing a sense of normality. Being with friends and their families, escaping difficulties at home without having to tell, was emphasised as important. Recognition was experienced when an adult with respect and dignity offered an open opportunity to address the problems, without pushing towards further communication. CONCLUSIONS Our study indicates some specific lessons to be learnt about recognition for professional service providers from everyday situations. Frames of recognition, communicating availability and normality, and also unconditional confidentiality and safety when sharing problems may also be offered by professionals in public healthcare within their current frames of competency and time.
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Affiliation(s)
- Anne Werner
- 1 Health Services Research Unit (HØKH), Akershus University Hospital, Lørenskog, Norway
| | - Kirsti Malterud
- 2 Research Unit for General Practice, Uni Research Health, Bergen, Norway.,3 Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,4 The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Denmark
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Fosse A, Ruths S, Malterud K, Schaufel MA. Doctors' learning experiences in end-of-life care - a focus group study from nursing homes. BMC Med Educ 2017; 17:27. [PMID: 28143600 PMCID: PMC5282814 DOI: 10.1186/s12909-017-0865-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 01/20/2017] [Indexed: 05/28/2023]
Abstract
BACKGROUND Doctors often find dialogues about death difficult. In Norway, 45% of deaths take place in nursing homes. Newly qualified medical doctors serve as house officers in nursing homes during internship. Little is known about how nursing homes can become useful sites for learning about end-of-life care. The aim of this study was to explore newly qualified doctors' learning experiences with end-of-life care in nursing homes, especially focusing on dialogues about death. METHODS House officers in nursing homes (n = 16) participated in three focus group interviews. Interviews were audiotaped and transcribed verbatim. Data were analysed with systematic text condensation. Lave & Wenger's theory about situated learning was used to support interpretations, focusing on how the newly qualified doctors gained knowledge of end-of-life care through participation in the nursing home's community of practice. RESULTS Newly qualified doctors explained how nursing home staff's attitudes taught them how calmness and acceptance could be more appropriate than heroic action when death was imminent. Shifting focus from disease treatment to symptom relief was demanding, yet participants comprehended situations where death could even be welcomed. Through challenging dialogues dealing with family members' hope and trust, they learnt how to adjust words and decisions according to family and patient's life story. Interdisciplinary role models helped them balance uncertainty and competence in the intermediate position of being in charge while also needing surveillance. CONCLUSIONS There is a considerable potential for training doctors in EOL care in nursing homes, which can be developed and integrated in medical education. This practice based learning arena offers newly qualified doctors close interaction with patients, relatives and nurses, teaching them to perform difficult dialogues, individualize medical decisions and balance their professional role in an interdisciplinary setting.
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Affiliation(s)
- Anette Fosse
- Research Unit for General Practice, Uni Research Health, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Sabine Ruths
- Research Unit for General Practice, Uni Research Health, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Kirsti Malterud
- Research Unit for General Practice, Uni Research Health, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Department of Public Health, The Research Unit for General Practice and Section of General Practice, University of Copenhagen, Copenhagen, Denmark
| | - Margrethe Aase Schaufel
- Research Unit for General Practice, Uni Research Health, Bergen, Norway
- Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway
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Bjørndal A, Borchgrevink CF, Frich J, Gulbrandsen P, Lie AK, Malterud K, Røttingen JA, Tellnes G, Westin S. Per Fugelli. Tidsskriftet 2017; 137:17-0800. [DOI: 10.4045/tidsskr.17.0800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Jansen K, Ruths S, Malterud K, Schaufel MA. The impact of existential vulnerability for nursing home doctors in end-of-life care: A focus group study. Patient Educ Couns 2016; 99:2043-2048. [PMID: 27435980 DOI: 10.1016/j.pec.2016.07.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 05/22/2016] [Accepted: 07/12/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE Explore the impact of existential vulnerability for nursing home doctors' experiences with dying patients and their families. METHODS We conducted a qualitative study based on three focus group interviews with purposive samples of 17 nursing home doctors. The interviews were audio-recorded, transcribed, and analyzed with systematic text condensation. RESULTS Nursing home doctors experienced having to balance treatment compromises in order to assist patients' and families' preparation for death, with their sense of professional conduct. This was an arduous process demanding patience and consideration. Existential vulnerability also manifested as powerlessness mastering issues of life and death and families' expectations. Standard phrases could help convey complex messages of uncertainty and graveness. Personal commitment was balanced with protective disengagement on the patient's deathbed, triggering both feelings of wonder and guilt. CONCLUSION Existential vulnerability is experienced as a burden of powerlessness and guilt in difficult treatment compromises and in the need for protective disengagement, but also as a resource in communication and professional coping. PRACTICE IMPLICATIONS End-of-life care training for nursing home doctors should include self-reflective practice, in particular addressing treatment compromises and professional conduct in the dialogue with patient and next-of-kin.
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Affiliation(s)
- Kristian Jansen
- Research Unit for General Practice, Uni Research Health, Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, Norway.
| | - Sabine Ruths
- Research Unit for General Practice, Uni Research Health, Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, Norway
| | - Kirsti Malterud
- Research Unit for General Practice, Uni Research Health, Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, Norway; Research Unit for General Practice in Copenhagen, Denmark
| | - Margrethe Aase Schaufel
- Research Unit for General Practice, Uni Research Health, Bergen, Norway; Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway
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Werner A, Malterud K. ``The pain isn't as disabling as it used to be'': How can the patient experience empowerment instead of vulnerability in the consultation? Scand J Public Health 2016; 66:41-6. [PMID: 16214722 DOI: 10.1080/14034950510033363] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Aim: This study explores how doctors can help patients transform vulnerability into strength, instead of increasing a feeling of disempowerment. Methods: The authors analysed their findings from four previously written articles based on qualitative interviews with 10 women with chronic pain, comparing the reported negative consultation experiences with the beneficial effects of good treatment experiences, in order to identify potentials for change. Results: Altering the way in which the women are encountered may empower and help them deal with a painful life. Doctors can challenge stereotyped macro-structures of women's ``unexplained'' pain as hysteria by admitting the shortcomings of medical knowledge. The blame is then put on the medical discipline instead of the individual patient who presents bodily symptoms or reveals help-seeking behaviour that does not fit with biomedical expectations of what illness is and how it should be performed. Thus, the vulnerable position described by the patients can be converted or transformed into strength or resources in spaces that promote empowerment through recognition. Conclusion: Although doctors may feel helpless or puzzled in the consultation, they must take the responsibility for turning the consultation into a space for empowerment of the patient.
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Affiliation(s)
- Anne Werner
- Centre for Women's Studies and Gender Research, University of Oslo, Norway.
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Abstract
Sample sizes must be ascertained in qualitative studies like in quantitative studies but not by the same means. The prevailing concept for sample size in qualitative studies is "saturation." Saturation is closely tied to a specific methodology, and the term is inconsistently applied. We propose the concept "information power" to guide adequate sample size for qualitative studies. Information power indicates that the more information the sample holds, relevant for the actual study, the lower amount of participants is needed. We suggest that the size of a sample with sufficient information power depends on (a) the aim of the study, (b) sample specificity, (c) use of established theory, (d) quality of dialogue, and (e) analysis strategy. We present a model where these elements of information and their relevant dimensions are related to information power. Application of this model in the planning and during data collection of a qualitative study is discussed.
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Affiliation(s)
- Kirsti Malterud
- 1 University of Copenhagen, Copenhagen, Denmark
- 2 Uni Research Health, Bergen, Norway
- 3 University of Bergen, Bergen, Norway
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Malterud K, Bjorkman M. The Invisible Work of Closeting: A Qualitative Study About Strategies Used by Lesbian and Gay Persons to Conceal Their Sexual Orientation. J Homosex 2016; 63:1339-1354. [PMID: 26914706 DOI: 10.1080/00918369.2016.1157995] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The last decades have offered substantial improvement regarding human rights for lesbian and gay (LG) persons. Yet LG persons are often in the closet, concealing their sexual orientation. We present a qualitative study based on 182 histories submitted from 161 LG individuals to a Web site. The aim was to explore experiences of closeting among LG persons in Norway. A broad range of strategies was used for closeting, even among individuals who generally considered themselves to be out of the closet. Concealment was enacted by blunt denial, clever avoidance, or subtle vagueness. Other strategies included changing or eliminating the pronoun or name of the partner in ongoing conversations. Context-dependent concealment, differentiating between persons, situations, or arenas, was repeatedly applied for security or convenience. We propose a shift from "being in the closet" to "situated concealment of sexual orientation."
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Affiliation(s)
- Kirsti Malterud
- a Research Unit for General Practice , Uni Research Health , Bergen , Norway
- b Department of Global Public Health and Primary Care , University of Bergen , Bergen , Norway
- c Research Unit for General Practice in Copenhagen , Copenhagen , Denmark
| | - Mari Bjorkman
- a Research Unit for General Practice , Uni Research Health , Bergen , Norway
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Abstract
Aims: A study was undertaken to explore how menopausal women are affected by awareness of potential risk of osteoporosis. Methods: A qualitative interview study, including analysis of in-depth interviews with 17 women who independently gave views on risk, out of 24 women interviewed about their menopausal symptoms. The women were selected on the basis of a survey including 1261 women chosen at random, to cover a broad spectrum of Danish women, their menopausal experiences, and contact with the healthcare system. The study was part of a larger project targeting menopause. Results: Awareness of osteoporosis risk caused a feeling of uncertainty and worry in some women. Only women reacting in this way seemed to act in order to prevent future fractures. The affected women were puzzled to realize that risk-reducing medication could introduce new hazards. Most of the women had heard about osteoporosis related to menopause as culturally embedded knowledge. Conclusions: Making individual women uncertain and worried must be considered a potentially serious side effect of health promotion. The findings raise the question of whether introducing healthy people to the threat of future diseases is ethically justifiable. As hormonal treatment is no longer recommended for long-term use, it is suggested that the strong link between osteoporosis and menopause should be toned down when counselling menopausal women.
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Affiliation(s)
- Lotte Hvas
- Central Research Unit and Department of General Practice, University of Copenhagen, Panum Institute, Denmark.
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Abstract
Aim: The aim of this study was to explore gender and coping in primary health care patients, by comparing self-assessed health resources in men and women. Methods: Female and male patients' self-assessed health resources were identified by mean of key questions, developed separately for men and women. Patients' answers were audiotaped and analyzed qualitatively. An explorative gender comparative analysis was done. The setting comprised two women GPs and their consultations. The subjects were 37 consecutive female patients and 39 consecutive male patients aged 19-85 years. Results: The analysis indicated notable differences in spite of apparent similarities in self-assessed personal health resources in men and women. In men, personal strength was part of a proud identity, while women reported that they were able to manage because they just had to. Work was often mentioned as a health resource, but while men emphasized their well-being at work and a capacity to relax at home, women handled stressful tensions by diving into household activities. While men spoke of gaining health from being with others, women talked about social relations as contexts for gaining as well as giving health. Conclusion : None of the phenomena described by the respondents can be reasonably categorized as respectively problem-focused, emotion-focused or avoidance coping strategies. Asking people about their own ideas regarding health resources may provide more complex understandings of coping and gender. In a clinical setting skilful listening can prevent gender essentialism, where all men are regarded as different from all women.
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Affiliation(s)
- Kirsti Malterud
- Section for General Practice, Department of Public Health and Primary Health Care, University of Bergen, Norway, , Central Research Unit and Department of General Practice, University of Copenhagen, Panum Institute, Denmark
| | - Hanne Hollnagel
- Central Research Unit and Department of General Practice, University of Copenhagen, Panum Institute, Denmark
| | - Klaus Witt
- Central Research Unit and Department of General Practice, University of Copenhagen, Panum Institute, Denmark
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Abstract
This case study illustrates how the use of empowering dialogues in general practice can contribute to alternative images of women, by identifying and emphasizing their strong points. It is a single case study, sampled theoretically from a series of 37 consultations during which key questions about self-assessed health resources were put to women patients. Two women GPs and their consultations were studied. An 18-min dialogue between a 52-year-old woman GP and a 69-year-old woman patient with asthma and back pain was audiotaped and transcribed according to Nessa's principles, supported by pragmatic linguistic theory. The woman's answers changed the doctor's perception of the patient, from that of a passive and resigned sufferer, to that of a strong woman who was active in spite of her pain. Acknowledging this, alternative paths of management could be chosen. In conclusion, disempowering medicalization of women patients can be opposed by resource oriented dialogues in clinical work. However, to change cultural images requires more than individual action.
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Affiliation(s)
- Kirsti Malterud
- Division for General Practice, Department of Public Health and Primary Care, University of Bergen, Norway
| | - Hanne Hollnagel
- Department of General Practice, Institute of Public Health, University of Copenhagen, Denmark
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Werner A, Malterud K. Encounters with service professionals experienced by children from families with alcohol problems: A qualitative interview study. Scand J Public Health 2016; 44:663-670. [PMID: 27516443 DOI: 10.1177/1403494816661651] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM The aim of this study was to explore encounters with service professionals experienced in childhood and adolescence by children who grew up with parental alcohol abuse. We focused on their accounts from situations indicating children's struggles or parental drinking problems. METHODS Semi-structured qualitative interview study was conducted with retrospective data from nine adults. Systematic text condensation was used to understand childhood experiences from encounters with professionals. RESULTS Participants believed that professionals rarely recognised their parents' drinking problems. The children felt abandoned by professionals who must have noticed their struggles. Participants experienced that their appearance or behaviour was ignored and that they were not invited to talk. Professionals taking part in individual family members' problems seemed to avoid subsequent involvement in underlying parental drinking. Even when problems were obvious, participants felt that professionals took no further action. Medical and social problems were managed within very confined perspectives. CONCLUSIONS Specific commitment to confront cultural taboos is needed to attend to children's unmet needs. Recognising each young person's situation implies not only noticing that something is wrong, but also taking action. Children's experiences of fragmented and confined approaches towards parental drinking problems may be counteracted by better collaboration between teachers, school nurses and GPs.
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Affiliation(s)
- Anne Werner
- 1 Health Services Research Unit (HØKH), Akershus University Hospital, Norway
| | - Kirsti Malterud
- 2 Research Unit for General Practice, Uni Research Health, Norway.,3 Department of Global Public Health and Primary Care, University of Bergen, Norway.,4 The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Denmark
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Ree E, Lie SA, Eriksen HR, Malterud K, Indahl A, Samdal O, Harris A. Reduction in sick leave by a workplace educational low back pain intervention: A cluster randomized controlled trial. Scand J Public Health 2016; 44:571-9. [PMID: 27307465 PMCID: PMC4941097 DOI: 10.1177/1403494816653854] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2016] [Indexed: 11/16/2022]
Abstract
Aims: The aim of this study was to investigate whether a workplace educational low back pain intervention had an effect on sick leave at the individual level and to identify possible predictors of the effect of intervention. Methods: Work units in two municipalities were cluster randomized to (a) educational meetings and peer support (45 units), (b) educational meetings, peer support and access to an outpatient clinic if needed (48 units) or (c) a control group (42 units). Both intervention groups attended educational meetings with information about back pain based on a non-injury model. A peer adviser was selected from among their colleagues. The outcome was days of sick leave at the individual level at 3, 6, 9 and 12 months, adjusting for previous sick leave at the unit level. As a result of similar effects on sick leave, the two intervention groups were merged (n=646) and compared with the control group (n=211). The predictors were different levels of belief in back pain myths, pain-related fear, helplessness/hopelessness and low back pain. Results: The intervention group had significantly less days of sick leave at the three month (4.9 days, p=0.001) and six month (4.4 days, p=0.016) follow ups compared with the control group. At three months, a low level of pain-related fear was the only predictor for the intervention effect (8.0 less days of sick leave, p<0.001). Conclusions: A workplace educational back pain intervention had an effect on sick leave for up to six months. A low score on pain-related fear was a predictor of the intervention effect.
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Affiliation(s)
- Eline Ree
- Uni Research Health, Uni Research, Norway Division of Physical Medicine and Rehabilitation, Vestfold Hospital Trust, Norway
| | - Stein Atle Lie
- Department of Clinical Dentistry, Faculty of Medicine and Dentistry, University of Bergen, Norway
| | - Hege R Eriksen
- Uni Research Health, Uni Research, Norway Department of Sport and Physical Activity, Bergen University College, Norway
| | - Kirsti Malterud
- Uni Research Health, Uni Research, Norway Department of Global Public Health and Primary Care, University of Bergen, Norway The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Denmark
| | - Aage Indahl
- Division of Physical Medicine and Rehabilitation, Vestfold Hospital Trust, Norway
| | - Oddrun Samdal
- Department of Health Promotion and Development, Faculty of Psychology, University of Bergen, Norway
| | - Anette Harris
- Department of Health Promotion and Development, Faculty of Psychology, University of Bergen, Norway Department of Psychosocial Science, Faculty of Psychology, University of Bergen, Norway
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Werner A, Malterud K. Children of parents with alcohol problems performing normality: A qualitative interview study about unmet needs for professional support. Int J Qual Stud Health Well-being 2016; 11:30673. [PMID: 27104341 PMCID: PMC4841096 DOI: 10.3402/qhw.v11.30673] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Children of parents with alcohol problems are at risk for serious long-term health consequences. Knowledge is limited about how to recognize those in need of support and how to offer respectful services. METHOD From nine interviews with adult children from families with alcohol problems, we explored childhood experiences, emphasizing issues concerning potentially unmet needs for professional support. Smart's perspective on family secrets and Goffman's dramaturgical metaphor on social order of the family focusing on the social drama and the dramaturgy enacted by the children supported our cross-case thematic analysis. FINDINGS The social interaction in the family was disrupted during childhood because of the parent's drinking problems. An everyday drama characterized by tension and threats, blame and manipulation was the backstage of their everyday life. Dealing with the drama, the children experienced limited parental support. Some children felt betrayed by the other parent who might trivialize the problems and excuse the drinking parent. Family activities and routines were disturbed, and uncertainty and insecurity was created. The children struggled to restore social order within the family and to act as normally as possible outside the family. It was a dilemma for the children to disclose the difficulties of the family. CONCLUSION Altogether, the children worked hard to perform a normally functioning family, managing a situation characterized by unmet needs for professional support. Adequate support requires recognition of the children's efforts to perform a normally functioning family.
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Affiliation(s)
- Anne Werner
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway;
| | - Kirsti Malterud
- Research Unit for General Practice, Uni Research Health, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Denmark
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Malterud K, Bjelland AK, Elvbakken KT. Evidence-based medicine - an appropriate tool for evidence-based health policy? A case study from Norway. Health Res Policy Syst 2016; 14:15. [PMID: 26945751 PMCID: PMC4779248 DOI: 10.1186/s12961-016-0088-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 02/22/2016] [Indexed: 12/30/2022] Open
Abstract
Background Evidence-based policy (EBP), a concept modelled on the principles of evidence-based medicine (EBM), is widely used in different areas of policymaking. Systematic reviews (SRs) with meta-analyses gradually became the methods of choice for synthesizing research evidence about interventions and judgements about quality of evidence and strength of recommendations. Critics have argued that the relation between research evidence and service policies is weak, and that the notion of EBP rests on a misunderstanding of policy processes. Having explored EBM standards and knowledge requirements for health policy decision-making, we present an empirical point of departure for discussing the relationship between EBM and EBP. Methods In a case study exploring the Norwegian Knowledge Centre for the Health Services (NOKC), an independent government unit, we first searched for information about the background and development of the NOKC to establish a research context. We then identified, selected and organized official NOKC publications as an empirical sample of typical top-of-the-line knowledge delivery adhering to EBM standards. Finally, we explored conclusions in this type of publication, specifically addressing their potential as policy decision tools. Results From a total sample of 151 SRs published by the NOKC in the period 2004–2013, a purposive subsample from 2012 (14 publications) advised major caution about their conclusions because of the quality or relevance of the underlying documentation. Although the case study did not include a systematic investigation of uptake and policy consequences, SRs were found to be inappropriate as universal tools for health policy decision-making. Conclusions The case study demonstrates that EBM is not necessarily suited to knowledge provision for every kind of policy decision-making. Our analysis raises the question of whether the evidence-based movement, represented here by an independent government organization, undertakes too broad a range of commissions using strategies that seem too confined. Policymaking in healthcare should be based on relevant and transparent knowledge, taking due account of the context of the intervention. However, we do not share the belief that the complex and messy nature of policy processes in general is compatible with the standards of EBM.
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Affiliation(s)
- Kirsti Malterud
- Research Unit for General Practice, Uni Research Health, Kalfarveien 31, N-5032, Bergen, Norway. .,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway. .,The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
| | | | - Kari Tove Elvbakken
- Department of Administration and Organization Theory, University of Bergen, Bergen, Norway
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Krag MØ, Hasselbalch L, Siersma V, Nielsen ABS, Reventlow S, Malterud K, de Fine Olivarius N. The impact of gender on the long-term morbidity and mortality of patients with type 2 diabetes receiving structured personal care: a 13 year follow-up study. Diabetologia 2016; 59:275-85. [PMID: 26607637 DOI: 10.1007/s00125-015-3804-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 10/19/2015] [Indexed: 12/15/2022]
Abstract
AIMS/HYPOTHESIS The aim of this study was to assess gender differences in mortality and morbidity during 13 follow-up years after 6 years of structured personal care in patients with type 2 diabetes mellitus. METHODS In the Diabetes Care in General Practice (DCGP) multicentre, cluster-randomised, controlled trial (ClinicalTrials.gov registration no. NCT01074762), 1,381 patients newly diagnosed with type 2 diabetes were randomised to receive 6 years of either structured personal care or routine care. The intervention included regular follow-up, individualised goal setting and continuing medical education of general practitioners participating in the intervention. Patients were re-examined at the end of intervention. This observational analysis followed 970 patients for 13 years thereafter using national registries. Outcomes were all-cause mortality, incidence of diabetes-related death, any diabetes-related endpoint, myocardial infarction, stroke, peripheral vascular disease and microvascular disease. RESULTS In women, but not men, a lower HR for structured personal care vs routine care emerged for any diabetes-related endpoint (0.65, p = 0.004, adjusted; 73.4 vs 107.7 events per 1,000 patient-years), diabetes-related death (0.70, p = 0.031; 34.6 vs 45.7), all-cause mortality (0.74, p = 0.028; 55.5 vs 68.5) and stroke (0.59, p = 0.038; 15.6 vs 28.9). This effect was different between men and women for diabetes-related death (interaction p = 0.015) and all-cause mortality (interaction p = 0.005). CONCLUSIONS/INTERPRETATION Compared with routine care, structured personal diabetes care reduced all-cause mortality and diabetes-related death in women but not in men. This gender difference was also observed for any diabetes-related outcome and stroke but was not statistically significant after extensive multivariate adjustment. These observational results from a post hoc analysis of a randomised controlled trial cannot be explained by intermediate outcomes like HbA1c alone, but involves complex social and cultural issues of gender. There is a need to rethink treatment schemes for both men and women to gain benefit from intensified treatment efforts.
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Affiliation(s)
- Marlene Ø Krag
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, P.O. Box 2099, DK-1014, Copenhagen K, Denmark.
| | - Lotte Hasselbalch
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, P.O. Box 2099, DK-1014, Copenhagen K, Denmark
| | - Volkert Siersma
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, P.O. Box 2099, DK-1014, Copenhagen K, Denmark
| | - Anni B S Nielsen
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, P.O. Box 2099, DK-1014, Copenhagen K, Denmark
| | - Susanne Reventlow
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, P.O. Box 2099, DK-1014, Copenhagen K, Denmark
| | - Kirsti Malterud
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, P.O. Box 2099, DK-1014, Copenhagen K, Denmark
- Research Unit for General Practice, Uni Health Research, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Niels de Fine Olivarius
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, P.O. Box 2099, DK-1014, Copenhagen K, Denmark
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Abstract
Objective: In this article, I want to promote theoretical awareness and commitment among qualitative researchers in general practice and suggest adequate and feasible theoretical approaches. Approach: I discuss different theoretical aspects of qualitative research and present the basic foundations of the interpretative paradigm. Associations between paradigms, philosophies, methodologies and methods are examined and different strategies for theoretical commitment presented. Finally, I discuss the impact of theory for interpretation and the development of general practice knowledge. Main points: A scientific theory is a consistent and soundly based set of assumptions about a specific aspect of the world, predicting or explaining a phenomenon. Qualitative research is situated in an interpretative paradigm where notions about particular human experiences in context are recognized from different subject positions. Basic theoretical features from the philosophy of science explain why and how this is different from positivism. Reflexivity, including theoretical awareness and consistency, demonstrates interpretative assumptions, accounting for situated knowledge. Different types of theoretical commitment in qualitative analysis are presented, emphasizing substantive theories to sharpen the interpretative focus. Such approaches are clearly within reach for a general practice researcher contributing to clinical practice by doing more than summarizing what the participants talked about, without trying to become a philosopher. Conclusions: Qualitative studies from general practice deserve stronger theoretical awareness and commitment than what is currently established. Persistent attention to and respect for the distinctive domain of knowledge and practice where the research deliveries are targeted is necessary to choose adequate theoretical endeavours.
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Affiliation(s)
- Kirsti Malterud
- Research Unit for General Practice, Uni Health Research, Bergen, Norway
- Research Unit for General Practice in Copenhagen, Denmark
- Department of Global Public Health and Primary Care, University of Bergen, Norway
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Abstract
The aim of this article is to present a conceptual review and analysis of symptom understanding. Subjective bodily sensations occur abundantly in the normal population and dialogues about symptoms take place in a broad range of contexts, not only in the doctor's office. Our review of symptom understanding proceeds from an initial subliminal awareness by way of attribution of meaning and subsequent management, with and without professional involvement. We introduce theoretical perspectives from phenomenology, semiotics, social interactionism, and discourse analysis. Drew Leder's phenomenological perspectives deal with how symptom perception occurs when any kind of altered balance brings forward a bodily attention. Corporeality is brought to explicit awareness and perceived as sensations. Jesper Hoffmeyer's biosemiotic perspectives provide access to how signs are interpreted to attribute meaning to the bodily messages. Symptom management is then determined by the meaning of a symptom. Dorte E. Gannik's concept "situational disease" explains how situations can be reviewed not just in terms of their potential to produce signs or symptoms, but also in terms of their capacity to contain symptoms. Disease is a social and relational phenomenon of containment, and regulating the situation where the symptoms originate implies adjusting containment. Discourse analysis, as presented by Jonathan Potter and Margaret Wetherell, provides a tool to notice the subtle ways in which language orders perceptions and how language constructs social interaction. Symptoms are situated in culture and context, and trends in modern everyday life modify symptom understanding continuously. Our analysis suggests that a symptom can only be understood by attention to the social context in which the symptom emerges and the dialogue through which it is negotiated.
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Affiliation(s)
- Kirsti Malterud
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
- Research Unit for General Practice, Uni Research Health, Kalfarveien 31, 5018, Bergen, Norway.
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.
| | - Ann Dorrit Guassora
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Anette Hauskov Graungaard
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Susanne Reventlow
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Dahl B, Malterud K. Neither father nor biological mother. A qualitative study about lesbian co-mothers' maternity care experiences. Sexual & Reproductive Healthcare 2015; 6:169-73. [DOI: 10.1016/j.srhc.2015.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 02/04/2015] [Accepted: 02/16/2015] [Indexed: 10/24/2022]
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Røthing M, Malterud K, Frich JC. Balancing needs as a family caregiver in Huntington's disease: a qualitative interview study. Health Soc Care Community 2015; 23:569-576. [PMID: 25471490 DOI: 10.1111/hsc.12174] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/14/2014] [Indexed: 06/04/2023]
Abstract
Family members in families with severe chronic disease play important roles in care-giving. In families affected by Huntington's disease (HD), caregivers encounter practical and emotional challenges and distress. Enduring caregiver burdens may lead to problems and caregivers are in need of social support and health services to deal with challenges. We wanted to explore coping strategies and behaviour patterns used by family caregivers to care for themselves, while caring for a family member with HD. Participants were recruited from hospitals and community-based healthcare. The sample represents experiences from care-giving in all stages of the disease. We conducted semi-structured interviews with 15 family caregivers in Norway. The transcribed material was analysed by use of systematic text condensation, a method for cross-case thematic analysis of qualitative data. We found that family members used various coping strategies, adjusted to the stage and progression of HD. They tried to regulate information about the disease, balancing considerations for protection and disclosure, within and outside the family. The participants made efforts to maintain a balance between their own needs in everyday life and the need for care for affected family member(s). As the disease progressed, the balance was skewed, and the family caregivers' participation in social activities gradually decreased, resulting in experiences of isolation and frustration. In later stages of the disease, the need for care gradually overshadowed the caregivers' own activities, and they put their own life on hold. Health professionals and social workers should acknowledge that family caregivers balance their needs and considerations in coping with HD. They should, therefore, tailor healthcare services and social support to family caregivers' needs during the different stages of HD to improve caregivers' abilities to maintain some of their own activities, in balance with care-giving.
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Affiliation(s)
- Merete Røthing
- Research Network on Integrated Health Care in Western Norway, Helse Fonna Local Health Authority, Haugesund, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Norway
| | - Kirsti Malterud
- Department of Global Public Health and Primary Care, University of Bergen, Norway
- Research Unit for General Practice, Uni Research Health, Bergen, Norway
- Research Unit for General Practice in Copenhagen, Denmark
| | - Jan C Frich
- Institute of Health and Society, University of Oslo, Norway
- Department of Neurology, Oslo University Hospital, Norway
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Røthing M, Malterud K, Frich JC. Family caregivers' views on coordination of care in Huntington's disease: a qualitative study. Scand J Caring Sci 2015; 29:803-9. [PMID: 25920040 DOI: 10.1111/scs.12212] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 12/09/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Collaboration between family caregivers and health professionals in specialised hospitals or community-based primary healthcare systems can be challenging. During the course of severe chronic disease, several health professionals might be involved at a given time, and the patient's illness may be unpredictable or not well understood by some of those involved in the treatment and care. AIM The aim of this study was to explore the experiences and expectations of family caregivers for persons with Huntington's disease concerning collaboration with healthcare professionals. METHODS To shed light on collaboration from the perspectives of family caregivers, we conducted an explorative, qualitative interview study with 15 adult participants experienced from caring for family members in all stages of Huntington's disease. Data were analysed with systematic text condensation, a cross-case method for thematic analysis of qualitative data. RESULTS We found that family caregivers approached health services hoping to understand the illness course and to share their concerns and stories with skilled and trustworthy professionals. Family caregivers felt their involvement in consultations and access to ongoing exchanges of knowledge were important factors in improved health services. They also felt that the clarity of roles and responsibilities was crucial to collaboration. CONCLUSIONS Family caregivers should be acknowledged for their competences and should be involved as contributors in partnerships with healthcare professionals. Our study suggests that building respectful partnerships with family caregivers and facilitating the mutual sharing of knowledge may improve the coordination of care. It is important to establish clarity of roles adjusted to caregivers' individual resources for managing responsibilities in the care process.
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Affiliation(s)
- Merete Røthing
- Research Network on Integrated Health Care in Western Norway, Helse Fonna Local Health Authority, Haugesund, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Kirsti Malterud
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Research Unit for General Practice, Uni Research Health, Bergen, Norway.,Research Unit for General Practice in Copenhagen, Copenhagen, Denmark
| | - Jan C Frich
- Institute of Health and Society, University of Oslo, Oslo, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway
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